Optum Eps User Authorization Agreement

3 Sending Information Reason to deposit: New registration change registration You must submit either a cancelled cheque or a bank letter to verify your bank account information. The bank name, bank code and bank account number must match the information provided at the time of registration. Do you want to deposit a cheque or a bank letter for supporting documents? Include with registration deposit: IMPORTANT Bank Bulletin Check: Please register a cancelled cheque here or copy the check/bank letter for the TIN and for each NPI bank account you register and fax it with the registration form. Please note that the ACH routing number in your cheque may differ from the ACH routing number, which is identified by your bank`s official bank letter. If it differs, the ACH routing number identified in the bank letter is the number you should include in the Financial Institution Information section. The undersigned herein certifies that the information contained in this document is accurate and accurate in all respects and that he has the right, if necessary, by all necessary and appropriate business measures to execute the agreement on behalf of the aforementioned organization name in order to conclude a legally binding contract, and understands that the acceptance of this agreement constitutes an agreement that is required to implement it in strict compliance with the terms set out in this Agreement. Written signature of the person filing the registration: Printed name of the person filing the registration: Phone number of the person who files the registration: address of the person who files the registration: thank you for faxing the signed registration form, a copy of a bank letter or a cancelled cheque (e) and your W-9 filled to Attn: Processing Manager (800) Or If you prefer, you can send all necessary and signed forms to Optum EPS, Attn: Processing Manager, P.O.Box 30777, Salt Lake City, UT registrations are usually processed within 5 business days of receiving your form. We will receive the organizers` contacts indicated in the registration with your EPS validity date and your first registration with EPS. W-9 By sending a W-9, you confirm that the information you provide on the Tax Identification Number (TIN) is true and correct. The name of TIN and the organization of Section 1 must correspond to the TIN/EIN number and the name or name of the company on the federal W-9. The federal W-9 is used to certify the information you provide. Please note that EPS cannot complete your registration request without a copy of your W-9.

If your organization does not have a completed W-9 form, please follow this link to download and complete the form. Remittance Information Optum offers two solutions to get your electronic isp Provider Remittance Advice (EPRA). Access your Remittance Advice (EPRA) and 835 files through the EPS Provider Access portal. The connection via your user ID and password will be delivered to you after your registration form has been processed. If you need to purchase the consolidated HIPAA 835s from your clearing house or EDI provider. If you choose to receive file 835 through your clearing house or your EDI provider, you should contact them and request receipt of this file.

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